Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

@xirurgi_2025 - 863 - файл

.pdf

Скачиваний:

Добавлен:

29.08.2026

Размер:

10 Мб

Скачать

☆

<<< < Предыдущая 5 6 7 8 9 10 11 12 13 14 15 1617 / 4917 18 19 20 21 22 23 24 25 26 27 28 29 > Следующая >>>

142

https://t.me/med1917

142

CHAPTER16 Burns surgery

Guide forspeciﬁc burns

Burns of dierent sizes and depths and in dierent anatomical areas are all managed using a variety of the above techniques. Each patient must be managed on an individual basis, but examples of strategies for surgical management following commencement of resuscitation and stabilization are provided.

Small tomedium supercial partial thickness burns

Supercial partial thickness burns <40% TBSA, presenting within 24 hours of injury are often managed using Biobrane®. Under sedation or anaesthesia, cleaning and debridement of burned epithelium is performed, followed by application of Biobrane® and dressings which are removed at 24 hours for inspection. If the Biobrane® is adherent at this time, no further dressings are required. As re- epithelialization occurs in 10– 14 days, the Biobrane® spontaneously separates from the wound and is trimmed.

Alternatively, topical Silvadene (1% silver sulfadiazine), biological dressings, conventional dressings such as paran impregnated gauze or silicone sheet, or other synthetic dressings are applied and changed regularly until the wound heals.

Large supercial partial thickness burns

Burns >40% are more prone to contamination and infection and can have a high morbidity despite their supercial nature. For this reason, allograft is often used to achieve temporary cover following debridement. Once the patient is stabilized, this is replaced in a staged manner by autograft. Alternatives to allograft are the use of other biological dressings as described above.

Deep partial thickness burns

Whether large or small, early total wound excision and grafting is the preferred method of treatment for deep burns in order to limit the inammatory response. Where possible, the dermis is preserved by the use of tangential excision, and the wounds are covered with autologous split skin grafts. If donor sites are limited, temporary wound closure is achieved with allograft, biological or semi- biological dressings until the donor site heals suciently to re- harvest.

Alternatives are serial excision of the amount of burn wound that can be closed by the available donor site. Unexcised areas are treated with topical antimicrobials until the donor site becomes available. In particular, Flammacerium (silver sulfadiazine and cerium nitrate) can be useful as it creates a hard impermeable eschar, which decreases uid loss, invasive wound infection, morbidity and mortality. This may be useful in patients who are unt for total surgical excision in the initial stages.

Full thickness burns

Again, regardless of size, prompt total excision and wound closure of full thickness burns reduces morbidity and mortality. Burns <10% TBSA, or larger burns that present early may be amenable to tangential or sharp excision preserving fat. However, patients with burns through some or all of the fat, or those with colonized or infected wound may require fascial excision

https://t.me/med1917

GUIDE FORSPECIFIC BURNS

to obtain a graftable bed. Fascial excision also limits blood loss in massive burns. The timing of excision of very large burns is imperative, as blood loss in the rst 24 hours post burn is up to half of that when surgery is performed after this time. However, performing total excision of a burn >40% TBSA is undeniably a huge undertaking requiring numerous surgeons, anaesthetists and nurses. Units without these resources may choose to excise in several staged operations.

As before, autograft, meshed as necessary, is the preferred wound cover. For larger burns ‘sandwich grafts’ may be necessary. Alternatively, allograft or the biological or semi- biological dressings discussed above may be used as temporary wound cover, or permanent dermal replacement. These wounds are subsequently covered with autograft as it becomes available.

Anatomical areas ofspecial consideration

The face and neck are areas of cosmetic and functional importance. Even deep burns of the face are usually treated with topical antimicrobials or repeated allograft application until a viable wound bed is apparent. Very rarely are burns excised, in order to preserve as much contour and viable tissue as possible. Medium to thick split skin sheet autografts are used in aesthetic units, with quilting sutures used to preserve anatomical landmarks.

The glabrous skin of the hands is thick, highly specialized and usually heals. It is thus best to manage burns to the palm relatively conservatively. The dorsal skin is thin and usually requires excision and sheet grafting. Initially the hands should be splinted in a position of safety. Following graft inspection at 5days, gentle mobilization can commence.

Meshed split skin grafts should be placed onto the trunk with the interstices running horizontally. In the limbs, the meshed interstices should run longitudinally. The exception to this is around joints, where they should be perpendicular to the axis of the limb and not expanded.

143

144

https://t.me/med1917

144

CHAPTER16 Burns surgery

References

1. Barrow RE, Herndon DN. History of treatment of burns. In Herndon DN (ed.). Total burn care.

Philadelphia, PA:Saunders Elsevier, 2007; pp. 5– 6.

2. Herndon DN, Barrow RE, Rutan RL, etal. A comparison of conservative versus early excision

therapies in severely burned patients. Annals of Surgery 1986;204:547– 53.

3. Deitch EA, Wheelahan TM, Rose MP, etal. Hypertrophic burn scars:analysis of variables. Journal

of Trauma 1983;23:895– 8.

4. Desai MH, Herndon D, Broemeling L, etal. Early burn wound excision signicantly reduces blood

loss. Annals of Surgery 1990;221:73– 762.

5. Hart DW, Wolf SE, Baeuford RB, etal. Determinants of blood loss during primary burn excision.

Surgery 2001;130:396– 402.

6. Klein MB, Hunter S, Heimbach DM, etal. The Versajet water dissector:a new tool for tangiental

excision. Journal of Burn Care & Rehabilitation 2005; 26:483– 87.

7. Janzekovic Z. A new concept in the early excision and immediate grafting of burns. Journal of

Trauma 1970;10:1103– 8.

8. Muller M, Gahankari D, Herndon DN. Operative wound management. In Herndon DN (ed.)

Total burn care. Philadelphia, PA:Saunders Elsevier, 2007; pp. 179– 80.

9. Alexander JW, MacMillan BG, Law E, etal. Treatment of severe burns with widel y meshed skin

autograft and widely meshed akin allograft overlay. Journal of Trauma 1981;1:75– 78.

10. Baret JP, Dziewulski P, Ramzy PI, etal. Biobrane versus 1% sulver sulfadiazine in second- degree

paediatric burns. Plastic and Reconstructive Surgery 2000;105:62– 5.

11. Jeschke MG, Finnerty CC, Shahrokhi S, et al. Wound coverage technologies in burn care:novel

techniques. Journal of Burn Care & Research 2013;34:612– 20.

12. Heimbach DM, Warden GD, Luterman A, etal. Integra dermal regeneration template for burn

treatment. Journal of Burn Care & Rehabilitation 2003;24:42– 8.

13. Munster MA. Cultured skin f or massive burns. Aprospective, controlled trial. Annals of Surger y

1996;224:372– 5.

14. Gravante G, Di Fede MC, Araco A, etal. A randomized trial comparing ReCell system of epi-

dermal cells delivery versus classic skin grafts for the treatment of deep partial thickness burns. Burns 2007;33:966– 72.

15. Gar ner JP, Heppell PS. The use of Flammacerium in British burns units. Burns 2005;31:379– 82.

https://t.me/med1917

Chapter17

145

Burn wound dressings

Goals of burn healing 146 Denitive vs. temporary dressings 146 The ideal denitive burn dressing 147 Dressing composition 148 Negative Pressure Wound Therapy 150 Summary of burn wound dressings 150 Further reading 150

146

https://t.me/med1917

146

CHAPTER17 Burn wound dressings

Goals ofburn healing

The ultimate goal for all burns is to allow the wound to heal with the least amount of scarring, and this is directly related to the depth of burn injury. Supercial partial thickness burns and deeper burns of small area can be treated by suitable dressings alone and this is probably the most widely applied form of treatment for burns. Supercial partial thickness burns will heal by re- epithelialization from the keratinocyte reserve within the epidermal appendages, while smaller deeper burns will heal by a combination of wound contraction and re- epithelialization from the wound edge. In both cases, this can be supported and promoted by wound dressings, after appropriate debridement and cleansing. Numerous studies have shown that re- epithelialization occurs more rapidly in a moist wound environment and if there is no barrier to this cell migration such as clot, slough or infection.

Deﬁnitive vs. temporary dressings

Initial cover of the burns wound after initial rst aid needs to be simple, widely available, and eective to maintain the wound in a clean state, reduce pain, and protect from the external environment. Cling lm is widely regarded as the best option in the rst instance, although most marketed simple dressings such as Tulle gauze (Jelonet) and similar are reasonable options. Dressing ointments such as Flamazine should be avoided in the initial phase if transfer to a burns unit is required as it alters the appearance of the burn and making it dicult to assess.

https://t.me/med1917

THE IDEAL DEFINITIVE BURN DRESSING

The ideal deﬁnitive burn dressing

There are many characteristics of the ideal wound dressing (Box 17.1) and these principles can be applied to burn dressings. The key features of dressings that are required by burns surgeons include lack of adhesion, ease of pain- free dressing change, absorbency, and antimicrobial activity. Currently there is a lack of evidence to guide clinicians as to the ‘gold- standard’ dressing for burn injury.

Box 17.1 Characteristics ofthe “ideal” wound dressing

[1] Maintain a moist environment at the wound– dressing interface [2] Absorb excess exudate without leakage to the surface of the

dressing [3] Provide thermal insulation [4] Provide mechanical and bacterial protection [5] Allow gaseous and uid exchange [6] Absorbent to wound odour [7] Non- adherent to the wound and easily removed without trauma [8] Non- toxic, hypoallergenic and non- sensitizing to the patient and

medical professional [9] Sterile

[10] Cost- eective and easily available

147

148

https://t.me/med1917

148

CHAPTER17 Burn wound dressings

Dressing composition

In essence, all dressings consist of three components. There is a nonadherent interface layer that lies in direct contact with the wound surface, and this can allow wound interaction by the addition of compounds such as antimicrobials or biomolecules. Next, there is an absorbent layer that can sequester wound exudate and store it away from the wound interface, providing the essential ‘moist’ wound environment rather than a ‘wet’ wound. Finally, there is an adhesive layer that will allow the xation of the dressing to the patient, and importantly, not to the wound, regardless of burns size or anatomy. Such dressings may be prefabricated by a manufacturer, and some such dressings may combine all of these properties into a single layer dressing (eg. the hydrocolloids) which have variable adhesion depending upon wound moisture levels and inbuilt absorbency. While pre- fabricated, or composite, dressings are a useful ‘o the shelf ’ commodity, the variety of dressings that are available worldwide allows a specic tailor- made dressing to be created on a patient- by- patient basis. The combination of dierent interface layers, with topical antimicrobials; a variable degree of absorbency, which will depend upon wound exudate; and specic adhesive properties, depending upon the size of the burn wound and the anatomy involved, as well as such issues as hypersensitivity to specic dressings allows dressings to be varied according to wound microbiology, as well as clinician and patient requirements.

Interface layer

Non- adherent dressings

Typically a ne meshed material, either dry or combined with a hydrophobic agent. This will include the polyethylenes (eg. Telfa clear®), silicones (eg. Mepitel®) and impregnated gauze (eg. Jelonet®). These can all be combined with topical antimicrobials.

Silver

Silver has a long history as an antimicrobial agent dating back to antiquity. Since the 1970s, silver has been delivered in the nitrate from, or in combination with a sulphonamide antibiotic. More recently, the development of nanocrystalline silver, consisting of both silver oxides and metallic ions, has allowed enhanced solubility and controlled release of silver giving a broad spectrum of activity against Gram- positive and Gram- negative species, as well as yeasts and fungi. Silver sulfadiazine (synthesized from silver nitrate and sodium sulfadiazine) is the most commonly used prophylactic agent in burns dressings and is manufactured as a 1% concentration in a water- soluble cream base (Flamazine®). Local hypersensitivity has been reported, as well as transient leukopenia at 3– 5days post burn. Cerium nitrate silver sulfadiazine (Flammacerium®) is indicated for larger deep burns in patients who may not be candidates for early surgical debridement. The cerium appears to be benecial because of its eect on the eschar rather than wound infection, producing a tougher eschar that may seal the wound more eectively than silver sulfadiazine. Nanocrystalline silver dressings (eg. Acticoat®) consist of a exible rayon/ polyester sheet bonded to a polyethylene mesh and coated with a lm of silver which will elute over time

https://t.me/med1917

DRESSING COMPOSITION

when exposed to wound exudate, allowing dressings to be left in place for longer. Silver- containing dressings may exhibit toxicity to keratinocytes and broblasts. Currently, there is insucient evidence to establish whether silver- containing dressings or topical agents promote wound healing or prevent wound infection.

Iodine

Although iodine has a broad spectrum of activity of action against Grampositive and Gram- negative species, as well as yeasts and fungi, it has been shown to have potential toxicity to broblasts and keratinocytes and is rarely used in routine burn wound dressings. It may be applied as povidoneiodine solution (eg. Betadine®) or in combination with a knitted viscose fabric (Inadine®).

Other

Mupirocin (Bactroban®) has a spectrum of action against MRSA and polymyxin B/ bacitracin (Polyfax®) in combination have activity against Grampositive and Gram- negative species, and are commonly used for supercial burns to the face as well as infected wounds. Honey can improve healing times in supercial and partial thickness burns compared with some conventional dressings.

Biosynthetics

Biobrane® is a bilaminate dressing, comprising a silicone membrane bonded to a layer of nylon fabric mesh and coated with a monomolecular layer of type 1 collagen of porcine origin. It is designed to adhere to the wound until re- epithelialization is complete, providing exible semi- occlusive membrane through which the wound can be observed. It is indicated for supercial partial thickness burns (eg. scalds), especially in the paediatric age group, and can be manufactured as anatomical garments. It is also useful in desquamating skin conditions such as toxic epidermal necrolysis.

Absorbent layer

Absorbent gauze can be tailored to the level of wound exudate, but will need changing when saturated. Ahydrogel is a network of polymer chains that are hydrophilic and highly absorbent. Their ability to absorb more than their own weight in uid allows provision of a moist wound environment, preferential to wound healing. Hydrogels include the alginates (Sorbsan®, Kaltostat®) and synthetic carboxymethylcellulose (Aquacel®, Intrasite®), which can incorporate silver (eg. Aquacel®Ag).

Adhesive layer

The adhesive layer will secure the dressing in place, reducing shearing forces, thus providing comfort, reducing evaporative heat losses and acting as a protective barrier to the injured tissues. These include the occlusive polyurethane lm dressings (Tegaderm®, Opsite®), and the semi- occlusive polyester tapes (Mex®, Hypax®), employing acrylic adhesives. Dressings can also be secured in place with sutures or surgical staples for areas that are prone to shearing or dressing dislodgement.

149

150

https://t.me/med1917

150

CHAPTER17 Burn wound dressings

Negative Pressure Wound Therapy

Negative pressure wound therapy (NPWT) is the application of a negative pressure across a wound to aid wound via drainage of excess exudate and increasing localized blood ow. It is a three- component dressing consisting of an interface layer, absorbent layer (which is drained by negative pressure) and an occlusive lm (VAC®, Renasys®). Currently, there is a lack of evidence about whether NPWT therapy is eective in the treatment of partial thickness burns.

Summary ofburn wound dressings

Burns that are selected for treatment by dressings alone, or in combination with surgical debridement and skin grafting, require regular monitoring, both clinically and microbiologically. Wound photography allows a record to be made of wound progression. Modern dressings may allow a longer interval between dressing changes, but this should not be sacriced in favour of regular review. If wound healing progresses at the expected rate, then the comfort aorded by fewer changes of dressings is advantageous, but the poorly progressing wound should be treated aggressively with a custom- designed dressing which can be tailored for the individual needs of the patient.